System and method for managing payments for health care services

ABSTRACT

The health care payment techniques include a system, and/or a machine-readable storage media. In some embodiments of these techniques, the system includes a processor that executes instructions. The system further includes machine-readable storage media having the instructions stored therein, the instructions when executed by the computer system causing the computer system to implement a health care claim payment method. The method includes receiving a plurality of claims for a plurality of health care services provided by a plurality of health care service providers to a patient. The method further includes remitting payment for each claim in the plurality of claims in a single payment. The remitting step is performed before the participant has acknowledged the participant&#39;s obligation to pay for the health care service. The method further includes combining the claim from the health care provider and a plurality of additional health care providers into a master bill. The method further includes sending the master bill to the participant. This Abstract is provided for the sole purpose of complying with the Abstract requirement rules. This Abstract is submitted with the explicit understanding that it will not be used to interpret or to limit the scope or the meaning of the claims.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.11/706,600, filed Feb. 13, 2007, entitled “System and Method forManaging Payments for Health Care Services” which claims the benefit ofU.S. Provisional Application No. 60/850,034, filed on Oct. 6, 2006,entitled, “System and Method for Managing Payments for Health CareServices”. Both applications are herein incorporated by reference intheir entireties.

BACKGROUND

The present invention relates generally to systems and methods formanaging payments for health care services.

Modern health care systems often involve relationships between a numberof parties including patients, health care providers, employers,insurers and other providers of health care benefit plans, and theadministrators of such plans. For example, health care providers maycontract with multiple health care network provider organizations suchas preferred provider organizations (PPOs), health managementorganizations (HMOs), managed care organizations, insurers, orpoint-of-service plan providers. The network provider organizationprovides patients (or participants) with a list of the health careproviders participating in the network and which accept fees inaccordance with a fee schedule negotiated with the network providerorganization. While participants are free to choose among the universeof providers, financial and other incentives are built into theapplicable health care benefit plan for the participants to selectparticipating providers. Access to the network provider organization maybe supplied through their employer and/or other affiliation with anemployer organization. For example, the participant may be a retiree ormay be a dependent child of an employee. Membership may also be obtainedthrough other types of relationships, such as through a professionalorganization.

The relationship between the network provider organization, theprovider, the participant and the employer is defined by variousagreements. For example, based on the agreements it is determined atwhat price the health care provider will discount the cost of healthcare services for patients having access to the network providerorganization. After a health care service is provided, the health careprovider will issue a bill for health care services rendered to theparty responsible for administration of the benefit plan such as a thirdparty administrator. The third party administrator or the networkprovider organization then reprices the claim to reflect the agreed uponfee schedule. Following repricing, the third party administratoradjudicates the bill in accordance with the terms of the applicablehealth care benefit plan. Adjudication includes a determination of theallocation of responsibility for payment of the bill as between theemployer organization and the health care benefit plan participant. Thethird party administrator collects payment from the employerorganization for the employer portion of the claim. Where the charge forhealth care service is only partially payable by the employer, theparticipant is responsible for payment of the remaining charge. Theparticipant portion of the claim is typically billed directly to theparticipant by the health care provider.

The participant's personal obligation to the health care provider forhealth care services rendered is based upon a number of factorsincluding the health care benefit plan terms regarding annualdeductibles, required co-payments for services received, or requiredco-insurance payments. Therefore for example, where a participant hasreceived medical services worth $800 on the basis of the negotiated feeschedule, and the participant has a $300 deductible, the networkprovider organization may pay the health care provider $500 and thehealth care provider may obtain the remaining balance of $300 from theparticipant in satisfaction of the participant's deductible.

In contemporary health care billing programs, there are imbedded costsassociated with collecting the participant's portion of the health careclaim such as the cost of generating periodic statements, the issuanceof reminder notices on past due accounts and the cost of writing offuncollectible accounts receivable. These costs may be related to: (i)the retention of internal billing staff or the payment of fees toindependent billing and collection services; and (ii) the time value ofmoney lost on delayed payments. Some of these costs are specificallyattributable to a lack of clarity in the current billing systemresulting from bills received from providers or provider organizationsunknown to the patient such as from medical laboratories, diagnosticiansor ancillary health care service providers other than the patient'sprimary physician. The receipt of bills from unknown entities, thereceipt of multiple billing invoices from multiple providers, andcertain providers' delay in requesting payment for services eachcontribute to the lack of clarity in the health care system.

As a part of the claims adjudication process, a considerable number ofmailings are sent to the participant (e.g., statements of billedcharges, multiple explanations of benefits, notices, and otherinformation concerning services provided and the amounts to be paid tothe providers). In many cases, there is often a significant delaybetween the time when the service is first provided and the time whenthe final bill for the service is sent to the participant, at whichpoint the participant may have difficulty remembering what service wasperformed. Additionally, some of the services may have been provided byproviders with whom the participant did not directly interact (e.g.,laboratories that performed lab work for the participant at the requestof a doctor). In such instances, the participant may receive a bill froman unknown provider for services that were performed some time ago.Moreover, many jurisdictions have local and/or federal regulationsregarding the information that must be disclosed to health careparticipants in the medical bill. Typically, the bill is significantlylengthened as a result of these mandatory disclosures. Such bills can bevery confusing and annoying for the participant, particularly if thereare also billing errors as sometimes occur.

With contemporary billing arrangements, the providers typically bear therisks and costs associated with non-payment and/or late payment of theparticipant portion of the claim. In the best case scenario, theparticipant recognizes his or her obligation to pay and pays promptly.Even then, however, there is still significant delay between the timethe service is originally provided and the time when the providerfinally receives payment from the participant for the participantportion of the claim. If, on the other hand, the participant disputesthe bill, or is unable to pay promptly, then the provider faces furtherdelays in getting paid for its services and/or faces non-paymentaltogether. It has been estimated that 30-50% of the participant portionof medical claims is never recovered by the health care provider due tothe above-mentioned inefficiencies and risks in modern billing systems.

It would be desirable to provide improved systems and methods formanaging payments for health care services that would provide a lesscostly and more readily understandable mechanism for receiving paymentof the participant portion of the claim. It will be appreciated thatwhile certain features and advantages are described herein, the claimsare not limited to systems and methods which achieve any one or more ofthese features, but rather may also encompass systems and methods havingother features and advantages different than those described herein.

SUMMARY

In an exemplary embodiment, a computer-implemented method comprisesreceiving a plurality of claims for a plurality of health care servicesprovided by a plurality of health care service providers to a patient.The receiving step is being performed by program logic implemented bythe instructions stored in the machine-readable storage media. At leasta portion of the claims is payable by a participant in a benefits planand at least a portion of the claims is payable by a third party payor.The method further comprises remitting payment, by a payment servicessystem logic implemented by the instructions stored in themachine-readable storage media, for each claim in the plurality ofclaims. The payment of the entire claim is remitted in a single paymentincluding (i) remitting the portion of the claim payable by the thirdparty payor, and (ii) remitting the portion of the claim payable by theparticipant. The remitting step is initiated and performed by a paymentservices manager. The remitting step is performed before the participanthas acknowledged the participant's obligation to pay for the health careservice. The method further comprises combining the claim from thehealth care provider and a plurality of additional health care providersinto a master bill, and sending the master bill to the participant.

In another exemplary embodiment, a machine-readable storage media havingstored therein instructions that when executed cause a computer systemto implement a method for managing health care claims for health careservices received by a patient from a health care service provider. Themethod comprises establishing a predetermined amount of funds forpayment of at least one claim, the claim having a participant portionand a third party payor portion. The method further comprises receivingnotification of the claim. The method further comprises in response tothe receiving step, transferring funds, in a single payment, through adisbursement system to the health care service provider in payment ofthe participant portion of the claim and the third party payor portion.The transferring of funds step is performed before the participant hasacknowledged the participant's obligation to pay for the health careservice. The method further comprises combining, by a payment servicessystem logic implemented by the instructions stored in themachine-readable storage media, claim information from the health careprovider and a plurality of additional health care providers into amaster bill to be sent to a participant enrolled in a benefits plan. Themaster bill contains claim information for the health care provider andthe plurality of additional health care providers. The method furthercomprises itemizing, by the payment services system logic, claiminformation for each of the health care services provided to the patientby the health care provider and the plurality of additional health careproviders. The method further comprises tracking, by the paymentservices system logic, payment of the master bill by the participant.

In another exemplary embodiment, a system comprising a processor thatexecutes instructions and machine-readable storage media having theinstructions stored therein. The instructions when executed by thecomputer system cause the computer system to implement a health careclaim payment method. The method comprises receiving a plurality ofclaims for a plurality of health care services provided by a pluralityof health care service providers to a patient. The receiving isperformed by program logic implemented by the instructions stored in themachine-readable storage media. At least a portion of the claims ispayable by a participant in a benefits plan and at least a portion ofthe claims is payable by a third party payor. The method furthercomprises remitting payment, by a payment services system logicimplemented by the instructions stored in the machine-readable storagemedia, for each claim in the plurality of claims. Payment of the entireclaim is remitted in a single payment, including (i) remitting theportion of the claim payable by the third party payor, and (ii)remitting the portion of the claim payable by the participant. Theremitting step is initiated and performed by a payment services manager.The remitting step is performed before the participant has acknowledgedthe participant's obligation to pay for the health care service.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block diagram illustrating a payment services system and therelationship between the health care provider, health care participantand network provider organization with respect to the payment servicessystem, according to an exemplary embodiment.

FIG. 2 is a flow chart illustrating a method for managing health carebillable charges, according to any exemplary embodiment.

FIG. 3 is a block diagram illustrating the conversion of the billablecharge issued by the health care provider into a claim and subsequentpayment of the claim, according to an exemplary embodiment.

FIG. 4 is a block diagram illustrating a payment services system and aplurality of health care providers, according to an exemplaryembodiment.

FIG. 5 is a block diagram illustrating a payment services system and aplurality of employer organizations, according to an exemplaryembodiment.

FIG. 6 is a block diagram illustrating distribution to the paymentservices manager operating and reserve account, according to anexemplary embodiment.

FIG. 7 is a block diagram illustrating a lock box account, according toan exemplary embodiment.

FIG. 8 is a block diagram illustrating the statement with itemizedexplanation of benefits, according to an exemplary embodiment.

FIG. 9 is a block diagram of a computer system that may be used toimplement the payment services system of FIG. 1, according to anexemplary embodiment.

FIG. 10 is an illustration of a payment coupon, according to anexemplary embodiment.

FIG. 11 is an illustration of a master bill, according to an exemplaryembodiment.

FIG. 12 is an illustration of a master bill, according to an exemplaryembodiment.

FIG. 13 is an illustration of a master bill, according to an exemplaryembodiment.

DETAILED DESCRIPTION

Referring generally to FIGS. 1-9 and specifically to FIG. 1, FIG. 1 is ablock diagram of an exemplary payment services system 100 provided forassisting in the payment of health care services. The payment servicessystem 100 interfaces with a health care participant 110 (e.g., apatient) and health care providers 120 (e.g., hospitals, laboratories,physicians, psychologists, certified specialists, general practitioners,other health care professionals, and so on) to promptly issue payment tothe health care providers 120 for health care services rendered to thehealth care participant 110. The payment services system 100 includes apayment services manager 160, a third party administrator 170, a trustee180, and a treasury manager 190. The trustee 180 and the treasurymanager 190 may, for example, be implemented by a financial institution195 (e.g., an FDIC insured bank, insurance company, and so on). As willbe appreciated, system 100 may include fewer or additional entities. Forexample, a network provider organization 150 may be included. Also, aswill be appreciated, although various operations are described as beingperformed by different respective entities, the various operations maybe performed by any combination of entities which each perform one ormore of the operations described herein, and some operations may not benecessary and/or may be replaced with other operations in someembodiments. Also, although not shown as such, the operations performedby payment services system 100 may also be performed by one or more ofthe health care providers 120 and/or by one or more of the employerorganizations 140. Additionally, although in the exemplary embodiment,the payment services system 100 is described in the context ofself-funded health plans sponsored by employers, it will be appreciatedthat the payment services system 100 may be used in connection withother types of plans, including insured health benefit plans. In anexemplary embodiment, the payment services system 100 is implemented ina computer system 900 that comprises the individual computers systems ofthe entities 110-190 connected through a communication network 197, suchas the Internet, as described in greater detail below in connection withFIG. 9.

Referring now to FIGS. 2-3, FIGS. 2-3 show an example of overalloperation of the system of FIG. 1 according to an embodiment. FIG. 2 isa flowchart of a method for managing health care charges for servicesreceived by a participant, according to one exemplary embodiment. FIG. 3is a block diagram showing how a billable charge may be processed toresult in payment to a health care provider 120. It may be noted that,in FIG. 3, the reference numbers 220-280 correspond to steps 220-280shown in FIG. 2.

In one illustrated exemplary embodiment, a health care provider 120provides a health care service to a participant and generates a billablecharge at step 210. The health care service may be provided to theparticipant 110 directly (i.e., the participant 110 is the patient) orvicariously (e.g., the patient is a covered family member of theparticipant). At step 220, the billable charge is transmitted to thethird party administrator 170. At step 230, the third partyadministrator 170 may re-price and adjudicate the billable charge, e.g.,by discounting the billable charge under a prior agreement with thehealth care provider 120.

The repricing is undertaken according to the terms of an agreementbetween the health care provider and payment services manager or thirdparty administrator 170 or other party. The claim is adjudicatedaccording to the terms of one or more agreements 310, such as a healthcare benefit plan agreement, prompt payment system provider agreement,and/or other agreement. For example, the claim may be adjudicatedaccording to a health care benefit plan which is a contract, policy, orother document defining the features of a group health care plan orbenefit program, under which a payor (e.g., the participant 110 or theemployer organization 140) is obligated to pay for health care services.For example, during the adjudication process, the third partyadministrator 170 may determine whether the service will be covered inits entirety by the employer, in which case the network providerorganization 150 will submit any payment to the health care provider120. The third party administrator 170 may also determine during theadjudication process whether a deductible is to be paid (i.e., theamount a participant 110 is required to pay before a claim 320 forbenefits by the participant is eligible for reimbursement by the payor).The third party administrator may also determine the apportionment ofthe billable charge into an employer portion 330 (which the employerorganization 140 has responsibility for paying under the self-fundedhealth plan) and the participant portion 340 (which the participant 110has responsibility for paying under the self-funded health plan) as aresult of the inclusion of deductible co-payment or co-insuranceprovisions of the health care benefit plan.

At step 240, financial institution 195 and the employer organization 140are notified of the total amount of the claim payable to the provider120. At step 250, the employer organization 140 pays the employerportion 330 of the claim to the financial institution 195. At step 260,the payment services manager 160 pays the participant portion 340 of theclaim. The employer portion 330 of the claim and the participant portion340 of the claim may be paid differently in different embodiments. In anexemplary embodiment, described in greater detail below in connectionwith FIGS. 4-7, the employer organization 140 maintains an employerdeposit account 410 and an employer reserve account 420 with thefinancial institution 195 that serves as the trustee 180 and thetreasury manager 190. The employer organization 140 may wire funds fromthe deposit account 410 within 48 hours of receiving notification of theclaim 320. In such an embodiment, the third party administrator 170 maynotify the payment services manager 160 of the respective amounts of theemployer portion 330 and the participant portion 340 of the claim, andcoordinate payment of the portions 330 and 340 using funds deposited inthe accounts 410 and 420 and/or using funds deposited in other accounts,as described below. In other exemplary embodiments, payment occurs in adifferent manner.

At step 270, the participant 110 then pays the participant portion 340of the claim to the payment services manager 160. As may be noted,therefore, the provider 120 receives the participant portion 340 of theclaim prior to the participant 110 paying this amount. As a result, theprovider 120 receives payment earlier than if it received payment afterthe participant 110 paid this amount. In an exemplary embodiment, theprovider receives payment in 30 days or less, 20 days or less, 10 daysor less, or in another period of time. Also, in an exemplary embodiment,the provider 120 may be paid regardless whether the participant 110 paysthe participant portion 340 of the claim. Thus, risk of non-payment ofthe participant portion of the claim may be shifted to another one ofthe entities such as to the payment services manager 160, as describedbelow.

Referring now to FIGS. 4-7, FIGS. 4-7 show aspects of thepayment/funding mechanism (e.g., including the movement of money betweenvarious accounts) used in the payment services system 100 in greaterdetail, according to an exemplary embodiment. Specifically, FIG. 4 issimilar to FIG. 1, but shows aspects of the funding mechanism betweenthe health care providers 120 and the payment services system 100 ingreater detail.

As shown in FIG. 4, a billed charge is delivered by the provider 120 tothe third party administrator 170 and is processed by the third partyadministrator 170 and the payment services manager 160, as describedabove. The third party administrator 170 provides notification of thebilled charge to the employer organization 140. The payment servicesmanager 160 coordinates payment of the claim through the financialinstitution 195, which serves as the trustee 180 and the treasurymanager 190. To this end, a plurality of accounts are used including anemployer deposit account 410, an employer reserve account 420, a claimpayment account 430, a disbursement account 440, and provider depositaccounts 450.

The employer deposit account 410, which may comprise separate respectivesub-accounts for each employer, is used to receive and hold funds fromemployers for the payment of the employee portion 330 of claims from thehealth care providers 120. For example, at periodic intervals (e.g.,once per week, on a Monday), the third party administrator 170 maynotify each employer of the amount of claims to be funded for theupcoming week and may notify the trustee 180 of all expected wiretransfers by employer and relevant amounts. Each employer organization140 may then transfer funds into its respective claim payment account430, and the trustee 180 may notify the payment services manager 160 ofthe funds transfers received by employer organization and amount. Thefunds may be directly transferred into the claim payment account 430.Subsequently, these funds may be transferred to the disbursement account440 for payment of the employer portion of the health care claims.

The employer reserve account 420, which may also comprise separaterespective sub-accounts for each employer, is used to receive and hold areserve of funds for the payment of the participant portion 340 ofclaims from the health care providers 120. In an exemplary embodiment,the employer deposit account 420 holds a reserve amount of funds (e.g.,two weeks worth of payments) which is used on an interim basis to paythe participant portion 340 of claims from the health care providers120. Again, these funds may be transferred to the disbursement account440 for payment of the employer portion of the health care claims. Boththe employer portion and the employee portion of the claim are remittedto the provider in a single combined payment through the paymentservices manager 160. The funds that are disbursed for this purpose aresubsequently replenished with funds received from the participant 110when the participant pays the participant portion 340 of the claim (FIG.2, step 280). Therefore, the provider 120 may receive both the employerportion 330 and participant portion 340 of the claim 320 in a singlepayment. Additionally, the payment is received more promptly than if theprovider 120 was paid when the participant portion 340 of the claim 320was paid by the participant 110.

The claim payment account 430 is an intermediate account between theemployer accounts 410, 420 and the disbursement account 440. In anexemplary embodiment, claim payment account 430 is used to receive andhold funds after adjudication of related claims and prior to thetransfer of such funds to the provider disbursement account 440 to paysuch claims. In an exemplary embodiment, the claim payment account 430(and/or various sub-accounts) are owned by the consortium of variousemployer organizations 140 and managed by trustee 180. After a claim hasbeen adjudicated and the employer organization 140 has paid its portionof the claim to the financial institution 195, amounts are thentransferred from the claim payment account 430 to the disbursementaccount 440, where they are held until final disbursement to theprovider 120.

The disbursement account 440 is an intermediate account between theclaim reserve account 430 and the provider accounts 450. The trustee 180moves amounts to the disbursement account 440 to fund the employerportion 330 and participant portion 340 of the claim. For example, eachweek the payment services manager 160 may provide the trustee 180 withthe total amount for the claims to be paid within a predetermined periodof time (e.g., within two business days). The information may beprovided on an employer-by-employer basis. This information may then beused by the trustee to move the funds from the claims reserve account tothe provider disbursement account 440.

The provider deposit account 450, or health care provider's account,receives payments from the payment services system 100. For example, thepayment services manager 160 may provide the treasury manager 190 with aNACHA-formatted file containing transfer requirements for claims to befunded. This information may then be used by the treasury manager 190 totransfer funds from the disbursement account 440 to the provider depositaccount 450. This information may also be used to transfer a portion ofthe claim payment funds to a payment services manager reserve account610 and a payment services manager operating account 620, as describedin greater detail below in connection with FIG. 6. In an exemplaryembodiment, the provider deposit account 450 is established at the samefinancial institution that provides trustee services (trustee 180) andtreasury management services (treasury manager 190). In anotherembodiment, the provider deposit account 450 is established at anotherfinancial institution. In another exemplary embodiment, an insurancecompany provides trustee services, treasury management services and/orpayment services manager services.

Referring now to FIG. 5, FIG. 5 is similar to FIG. 1 but shows aspectsof the fund transfer mechanism between the payment services system 100and the employer organization 140 in greater detail. As shown in FIG. 5,in an exemplary embodiment, an employer organization 140 establishes atleast one account 510 for providing funding to the employer depositaccount 410 and the employer deposit account 420, as described above.The employer also receives claims information from the payment servicesmanager 160, as shown.

Referring now to FIG. 6, FIG. 6 shows the accounts 410-450 shown inFIGS. 4-5 as well as additional accounts 610 and 620. In an exemplaryembodiment, the payment services manager 160 charges at least onepayment services management fee in connection with each claim satisfiedthrough the payment services system 100. The fee may, for example, becalculated as a percentage of each transaction or payment made to ahealth care services provider 120. Thus, as shown in FIG. 6, the trusteetransfers a portion of the funds from claim payment account 430 to thepayment services manager reserve account 610 and the payment servicesmanager operating account 620 instead of to the disbursement account440. In this way, the claim payment account 430 acts as a holdingaccount. The payment services management fee compensates the paymentservices manager 160 for bearing the risk of loss undertaken by thepayment services manager 160 with respect to the collection ofdelinquent payments from participants 110 of the participant portions340 of the claims. The payment services management fee also compensatesthe payment services manager 160 for operating the payment servicessystem 100. In the illustrated embodiment, the fee is paid by theproviders 120, in as much as it is taken off the top as a percentage ofthe funds otherwise directed to the providers 120. In exchange, asindicated previously, the providers receive the benefits of quickerpayment and avoiding the risk of non-payment by the participant.

The payment services manager reserve account 610 is a reserve fundmaintained by the payment services manager 160 in the event ofdelinquency of a participant in paying the participant portion 340 of aclaim. As indicated previously, the participant portion 340 of claims isinitially paid using funds from the employer deposit account 420 for therespective employer 140 of that participant 110. Assuming theparticipant 110 pays in a timely manner, the funds received from theparticipant 110 are deposited back into the employer deposit account 420to replenish the funds that were earlier disbursed. However, if theparticipant 110 is delinquent in paying for more than a predeterminedperiod of time (e.g., the participant is more than 60 days delinquent),then the funds used to replenish the employer deposit account 420 areobtained from the payment services manager reserve account 610. Thus, aspreviously indicated, the payment services manager 160 bears the risk ofdelinquent payment by the participant 110. The funds that flow into thepayment services manager reserve account 610 are used to fund theliabilities incurred by the payment services manager 160 in connectionwith this risk. To the extent that an accumulated excess builds up inthe payment services manager reserve account 610, these funds compensatethe payment services manager 160 for accepting the risk of delinquency.In another embodiment, rather than having an accumulated excess buildup, the payment services manager 160 may manage the amount of fundsflowing into the payment services manager reserve account 610 toapproximately meet the incurred liabilities, and then take ascompensation unused funds from the payment services manager operatingaccount 620.

The payment services manager operating account 620 holds and disbursesoperating funds for business purposes of the payment services manager160. The payment services manager 160 may derive compensation from fundsthat are deposited in the payment services manager operating account 620that are in excess of the funds needed to operate the payment servicessystem 100.

As will be appreciated, other entities involved in the payment servicessystem 100 may receive compensation in other ways. For example, one ormore of the accounts 410-450 may be non-interest bearing accounts,thereby permitting the financial institution 195 to receive compensationin the form of access to interest-free funds maintained on deposit. Asanother example, the financial institution 195 (e.g., the trustee 180and/or the treasury manager 190) may charge fees on a per transactionbasis. The fee may be charged to the payment services manager 160, maybe charged to the providers 120, or may be charged to another entity.Other financial benefits may be exchanged between the entities 110-190.For example, in an exemplary embodiment, each provider 120 may agree toprovide a discount to participants 110 affiliated with the networkprovider organization 150. The discount may, for example, be greaterthan the discount(s) provided to any other network provider organization150 (e.g., except than programs maintained by the state or federalgovernment, such as Medicare and Medicaid).

Referring now to FIG. 7, in an exemplary embodiment, a lock box account710 is used to receive payments received from participants 110. As shownin FIG. 7, the lock box account 710 may be used for the receipt ofpayments from participants 110 and the transfer of such payments intothe appropriate employer deposit account 420 or the payment servicesmanager reserve account 610. Participants may mail payments to thefinancial institution 195 for disbursement into the lock box account710. The financial institution 195 processes the remittance and depositsthe funds into the lock box account 710. If a participant 110 waspreviously delinquent on a payment, and the payment services manager 160had transferred funds from the payment services manager reserve account610 to the employer reserve account 420, then the funds may betransferred to the payment services manager reserve account 610.Otherwise, the funds are deposited into the employer reserve account420, as previously described.

Referring now to FIG. 8, in an exemplary embodiment, the paymentservices manager 160 sends a master statement or master bill 800 orstatement for collection to the health care participants 110. In anexemplary embodiment, the master bill 800 may be generated by thecomputer platform 965 and mailed out to the participant on a periodicbasis (e.g., on a monthly basis). The master bill 800 may comprise astatement of all outstanding claims owed by the participant 110. Thestatement 800 may include an itemized explanation of benefits 810including a line item listing 820 of health care service provided byvarious providers 120 during the prior period (e.g., during the priormonth) and an identification 830 of the apportionment of the participantportion 340 and employer portion 330 of the claim 320 for each. Thestatement may also include information from individual bills fromindividual providers 120 concerning the services rendered by theindividual providers 120. For example, the billing information thatwould otherwise be sent by the providers 120 may be included asattachments in the master bill 800. The statement 800 may also be senton a non-periodic basis (e.g., a predetermined number of days after aservice is provided by a provider, and including any additionalitemizations for any additional services provided during the interveningperiod until the master bill 800 is sent).

In one embodiment, the statement 800 includes a payment coupon 840, asillustrated in FIG. 10, that the participant may use to remit payment tothe lock box account 710. The funds are forwarded to the bank treasurymanager 190. The payment coupon 840 may, for example, include thestatement number, an account number or participant identificationnumber, the total amount due, the amount owed, payment due date, and/orother information. If the amount required to be paid is less than theentirety of the participant portion 340, the payment coupon may includea minimum payment amount as well as a full payment amount. The couponmay also have a projected pay off date and/or the specific monthlypayment relative to the entire series of payments. The participant maythen render funds to the financial institution 195. Payment is receivedand deposited into the lock box account 710. The trustee 180 or treasurymanagement 190 will adequately distribute the funds to the employerdeposit account 420 to replenish funds that were previously used to paythe participant portion 340 of the claim and/or into the paymentservices manager reserve account 610, as described above in connectionwith FIG. 7.

In the exemplary embodiments illustrated FIGS. 11-13, the participant110 may be provided with a single, consolidated bill or “master bill”for all health care services received, e.g., during the preceding month.The master bill 800 may include a summary of account activity listingall previous balances, payments and additional chargers and/or newpatient responsibilities. Each payment is correlated with a specificservice date, a designated reference number and the total amount owed tothe health care service provider. The bill 800 may include more detailedinformation for the health care service received in an appended section.The master bill 800 includes references to the page number(s) where thehealth care service is discussed in greater detail. In this way, themaster bill 800 acts as a table of contents for more descriptiveportions of the medical bill. Accordingly, the health care participantmay determine the particular health care service in which previouspayments were applied. The master bill 800 may contain charges fromvarious individual providers 120 and may provide the participant 110with the ability to pay for the health care services from the variousproviders 120 in a single transaction (e.g., a single check paid inconnection with the payment coupon 840) as illustrated in FIG. 12.Additionally, by providing the information in a consolidated format, theparticipant 110 is given the ability to recognize the correlationbetween different related services provided by different providers 120.For example, the lab services provided by a provider 120 that wouldotherwise be unrecognized by the participant may be correlated by theparticipant 110 with a doctor visit in which the participant 110 recallsthat lab services were ordered. In another embodiment, the master bill800 includes a legend having detailed descriptions for medical terms,codes and/or acronyms related to medical services referenced in otherportions of the master bill, e.g., the explanation of benefits section.

Referring now to FIG. 9, FIG. 9 shows a computer system 900 whichimplements the payment services system 100. As shown in FIG. 9, thehealth care providers 120, the employer organizations 140, the networkprovider organizations 150, the payment services manager 160, the thirdparty administrator 170, the trustee 180, and the treasury manager 190may each have respective computer systems 915-990 (e.g., including oneor more servers and one or more user computers) that are interconnectedthrough a communication network 197, such as the Internet. The computersystem 900 permits the entities 110-190 interact with each otherelectronically.

In another exemplary embodiment, an identification card (e.g., a smartcard or other credit card-sized device) which has patient informationstored in a computer accessible medium is employed with the paymentservices system. The card may store information concerning patient care,insurance, health history, and so on. The card may be utilized inconjunction with the health care provider's data management system tostreamline the process of transferring information between theparticipant and provider.

As may be appreciated, the operations described herein as beingperformed by entities 110-190 may in practice be performed by thecomputer systems 910-990 associated with each of the respective entities110-190. That is, each of the computer systems 910-990 may includeprogram logic 915-995 configured to perform the operations describedherein as being performed by entities 110-190. Thus, for example, healthcare provider computer systems 920 may have bill generation and trackingprogram logic 925 which may, for example, be one or more softwareapplications executing on a computer and used to generate bills andtrack payment of the bills. Such program logic 925 may electronicallycommunicate claim information to claim adjudication logic 975 executingon the third party administrator computer systems 970, and so on.

In an exemplary embodiment, as previously described, the paymentservices manager 160 coordinates overall operation of the paymentservices system 100. As such, operations not specifically identified asbeing performed by another entity may be performed by the paymentservices manager computer system 960. As will also be appreciated, suchfunctions may be outsourced to an application service provider thatprovides a network-accessible platform on behalf of the payment servicesmanager 160 and/or on behalf of another one of the entities 110-190.

The participants 110 may also be provided with access (e.g., through aninternet-enabled web browser) to view account information that is storedby the payment services system logic 965. For example, the participants110 may be provided with the ability to log onto a website, provide userID/password information, and obtain access to health care serviceinformation for services provided by multiple ones of the providers 120,including their master bill 800 for the current and/or precedingperiods. Thus, the payment services system logic 965 may provide theparticipant with a central repository of billing and payment informationfor health care services that the participant 110 has received. As willbe appreciated, communication with the health care participants 110,such as to send out the master bills 800, may also occur through postalmail or in another manner.

Additionally, as indicated above, during operation of payment servicessystem 100, various information may be communicated between the entities110-190 using the computer systems 910-990. Examples of events involvingthe communication of such information by the computer system 960 of thepayment services manager 160 are as follows (many of which have beenpreviously mentioned): The payment services manager 160 may send amaster statement or master bill 800 or statement for collection to thehealth care participants 110. The payment services manager 160 mayprovide the trustee 180 with an aging report on any unpaid or delinquentparticipant accounts. The payment services manager 160 may advise thetrustee 180 of the need or desire to set up the claim payment account430 and disbursement account 440 on the behalf of the employerorganization 140. The payment services manager 160 may advise theemployer organization 140 of an account or deposit number associatedwith the employer accounts. The payment services manager 160 may notifythe employer of the reserve amount and may send the financialinstitution 195 wire instructions to transfer the reserve amount intothe claim payment account 430. The payment services manager 160 mayadvise each employer organization 140 of the amount needed for weeklyclaims (e.g., every Monday or the next business day thereafter in thecase of a holiday). The payment services manager 160 may provide aweekly wire transfer file to the bank to pay the third partyadministrator 170. The payment services manager 160 may notify (e.g.,throughout the fiscal calendar) the trustee 180 of running totals on theemployer reserve account 910 and the disbursement account 440. Thepayment services manager 160 may advise the trustee 180, for eachtransaction, of an employer identification number and whether theappropriate funds are withdrawn from the correlating employer reserveaccount.

Examples of events involving the communication of such information bythe computer system 980 and 990 of the financial institution 195(including the trustee 180 and the treasury manager 190) are as follows(many of which have been previously mentioned): The financialinstitution 195 may notify the payment services manager 160 account on aperiodic basis the dollars received by the participant. The financialinstitution 195 may periodically issue to the payment services manager160 a claims reserve report regarding the status of the claim reserveaccount 430 (e.g., an electronic report of all debits and credits to theclaim payment account 430 daily). The trustee 180 verifies with thepayment services manager 160 each day the wires received and the amountsexpected. The trustee 180 may deliver to the payment services manager160 an electronic report of all amounts received in the lock boxaccount. The trustee 180 and the payment services manager 160 may issuean electronic report of all debits and credits to each employer reserveaccount. The trustee 180 may periodically deliver to the paymentservices manager 160 an electronic report of all debits and credits tothe provider disbursement account 440.

It should be appreciated, of course, that the details associated withthe payment services system 100 described herein merely represent onepossible implementation. Other applications for this platform include,for example, medical, dental, vision, short-term disability insurance,COBRA/HIPAA administration, flexible spending accounts, and healthsavings accounts.

The foregoing description of embodiments of the invention has beenpresented for purposes of illustration and description. It is notintended to be exhaustive or to limit the invention to the precise formdisclosed, and modifications and variations are possible in light of theabove teachings or may be acquired from practice of the invention. Theembodiments were chosen and described in order to explain the principalsof the invention in various embodiments and with various modificationssuited to the particular use contemplated.

The invention is described herein with reference to drawings. Thesedrawings illustrate certain details of specific embodiments thatimplement the systems and methods and programs of the present invention.However, describing the invention with drawings should not be construedas imposing on the invention any limitations that may be present in thedrawings. The present invention contemplates methods, systems andprogram products on any machine-readable media for accomplishing itsoperations. The embodiments of the present invention may be implementedusing an existing computer processor, or by a special purpose computerprocessor incorporated for this or another purpose, or by a hardwiredsystem.

Embodiments within the scope of the present invention include programproducts comprising machine-readable media for carrying or havingmachine-executable instructions or data structures stored thereon. Suchmachine-readable media can be any available media which can be accessedby a general purpose or special purpose computer or other machine with aprocessor. By way of example, such machine-readable media can compriseRAM, ROM, EPROM, EEPROM, CD-ROM or other optical disk storage, magneticdisk storage or other magnetic storage devices, or any other mediumwhich can be used to carry or store desired program code in the form ofmachine-executable instructions or data structures and which can beaccessed by a general purpose or special purpose computer or othermachine with a processor. When information is transferred or providedover a network or another communications connection (either hardwired,wireless, or a combination of hardwired or wireless) to a machine, themachine properly views the connection as a machine-readable medium.Thus, any such connection is properly termed machine-readable medium.Combinations of the above are also included within the scope ofmachine-readable media. Machine-executable instructions comprise, forexample, instructions and data which cause a general purpose computer,special purpose computer, or special purpose processing machine toperform a certain operation or group of operations.

Embodiments of the present invention may be practiced in a networkedenvironment using logical connections to one or more remote computershaving processors. Logical connections may include a local area network(LAN) and a wide area network (WAN) that are presented here by way ofexample and not limitation. Such networking environments are commonplacein office-wide or enterprise-wide computer networks, intranets, theInternet and a wide variety of different communication protocols. Thoseskilled in the art will appreciate that such network computingenvironments will typically encompass many types of computer systemconfigurations, including personal computers, hand-held devices,multi-processor systems, microprocessor-based or programmable consumerelectronics, network personal computers, minicomputers, mainframecomputers, and the like. Embodiments of the invention may also bepracticed in distributed computing environments where tasks areperformed by local and remote processing devices that are linked (eitherby hardwired links, wireless links or by a combination of hardwired andwireless links) through a communications network. In a distributedcomputing environment, program modules may be located in both local andremote memory storage devices.

1. A computer-implemented method, the method comprising: receiving aplurality of claims for a plurality of health care services provided bya plurality of health care service providers to a patient, the receivingbeing performed by program logic implemented by the instructions storedin the machine-readable storage media, at least a portion of the claimsbeing payable by a participant in a benefits plan and at least a portionof the claims being payable by a third party payor; remitting payment,by a payment services system logic implemented by the instructionsstored in the machine-readable storage media, for each claim in theplurality of claims, payment of the entire claim in a single payment,including (i) remitting the portion of the claim payable by the thirdparty payor, and (ii) remitting the portion of the claim payable by theparticipant, wherein the remitting step is initiated and performed by apayment services manager, the remitting step being performed before theparticipant has acknowledged the participant's obligation to pay for thehealth care service; and combining the claim from the health careprovider and a plurality of additional health care providers into amaster bill, and sending the master bill to the participant.
 2. Themethod of claim 1, further comprising tracking receipt of payment fromthe participant for the participant's portion of the plurality ofclaims.
 3. The method of claim 1, wherein the sending step is performedby the payment services manager.
 4. The method of claim 1, wherein theparticipant is the patient on whom the health care service is performed.5. The method of claim 1, wherein the patient on whom the health careservice is performed is a family member of the participant or otherperson covered by the participant's benefits plan.
 6. The method ofclaim 1, wherein remitting payment further includes (iii) accepting riskof delinquency and/or non-payment by the participant.
 7. The method ofclaim 1, wherein the third party payor is an employer of theparticipant.
 8. The method of claim 1, wherein the third party payor isan insurer associated with the benefits plan.
 9. The method of claim 1,wherein the payment services manager and the third party payor aredifferent entities.
 10. The method of claim 1, wherein the paymentservices manager and the third party payor are the same entity.
 11. Themethod of claim 10, wherein the third party payor is an insurerassociated with the benefits plan.
 12. Machine-readable storage mediahaving stored therein instructions that when executed cause a computersystem to implement a method for managing health care claims for healthcare services received by a patient from a health care service provider,the method comprising: establishing a predetermined amount of funds forpayment of at least one claim, the claim having a participant portionand a third party payor portion; receiving notification of the claim; inresponse to the receiving step, transferring funds, in a single payment,through a disbursement system to the health care service provider inpayment of the participant portion of the claim and the third partypayor portion, the transferring of funds step being performed before theparticipant has acknowledged the participant's obligation to pay for thehealth care service; combining, by a payment services system logicimplemented by the instructions stored in the machine-readable storagemedia, claim information from the health care provider and a pluralityof additional health care providers into a master bill to be sent to aparticipant enrolled in a benefits plan, the master bill containingclaim information for the health care provider and the plurality ofadditional health care providers; itemizing, by the payment servicessystem logic, claim information for each of the health care servicesprovided to the patient by the health care provider and the plurality ofadditional health care providers; and tracking, by the payment servicessystem logic, payment of the master bill by the participant.
 13. Themachine-readable storage media of claim 12, wherein the funds are equalto the sum of the third party payor portion and the participant portionof the claim.
 14. The machine-readable storage media of claim 13,wherein the instructions when executed cause the computer system to:issue a report periodically accounting for funds received anddistributed to the third party payor.
 15. The machine-readable storagemedia of claim 12, wherein the instructions when executed cause thecomputer system to: produce an electronic transaction with an expectedamount for monitoring funds, wherein the producing occurs periodically.16. The machine-readable storage media of claim 12, wherein theinstructions when executed cause the computer system to: issue a reporton any delinquency.
 17. A computer system comprising: a processor thatexecutes instructions; and machine-readable storage media having theinstructions stored therein, the instructions when executed by thecomputer system causing the computer system to implement a health careclaim payment method comprising receiving a plurality of claims for aplurality of health care services provided by a plurality of health careservice providers to a patient, the receiving being performed by programlogic implemented by the instructions stored in the machine-readablestorage media, at least a portion of the claims being payable by aparticipant in a benefits plan and at least a portion of the claimsbeing payable by a third party payor; and remitting payment, by apayment services system logic implemented by the instructions stored inthe machine-readable storage media, for each claim in the plurality ofclaims, payment of the entire claim in a single payment, including (i)remitting the portion of the claim payable by the third party payor, and(ii) remitting the portion of the claim payable by the participant,wherein the remitting step is initiated and performed by a paymentservices manager, the remitting step being performed before theparticipant has acknowledged the participant's obligation to pay for thehealth care service.
 18. The computer system of claim 17, wherein theparticipant is the patient on whom the health care service is performed.19. The computer system of claim 17, wherein the patient on whom thehealth care service is performed is a family member of the participant.20. The computer system of claim 17, wherein the third party payor is anemployer of the participant.
 21. The computer system of claim 17,wherein the third party payor is an insurer or other associated partyassociated with the benefits plan.